Approach to Dizziness

December 4, 2001Swedish Family MedicineDobrina Okorn, MD

Clinical Scenario

It’s 2:50pm and your 2:45 is being placed in a room. Your next patient is scheduled at 3:00pm and you’ve given up trying to dictate between patients. Your nurse hands you the chart, on the front of which the chief complaint and blood pressure are written: “Dizziness”, 148/86. You emit an almost-silent groan and gather your thoughts before entering the room.

Differential

40% Peripheral vestibular dysfunction10% Central brainstem vestibular lesion 25% Presyncope or disequilibrium15% Psychiatric disorder10% Unknown cause

Case continues...

You quickly review the chart and see that the pt is a 47 yo gentleman with no significant PMH (he was last seen one year ago for a mole removal) and is on no medications; you enter the room.

He tells you that last week, all of a sudden, he was attacked by episodes of dizziness -- yeah, the room was spinning around him, how did you know? -- sometimes just while standing still, sometimes when he turned over in bed. Each lasted less than a minute or two and then he’d be fine.

Vestibular dysfunction...

Peripheral causes canalithiasis (BPPV) --

50% vestibular neuronitis

(labyrinthitis) -- 25% Meniere’s disease --

10% trauma drugs

(aminoglycosides)

Central causes vascular

(vertebrobasilar insufficiency) -- 50%

demyelinating (multiple sclerosis)

drugs (anticonvulsants, alcohol, hypnotics)

Vertigo vs. other types of dizziness

Time course -- vertigo is never continuous

Provoking factors -- spontaneously or with positional changes

Aggravating factors -- all vertigo is made worse by moving the head

Establishing the cause of vertigo (Pt 1)

Time course BPPV: lasts less than one minute, self-

limited, responds poorly to anti-vertigo drugs Vascular: single episode lasting minutes to

hours; usually due to migraine or to transient ischemia of the labyrinth or brainstem; occasionally Meniere’s disease

Recent onset of more prolonged episodes characteristic of vestibular neuronitis, multiple sclerosis, vertebrobasilar ischemia

Establishing the cause of vertigo (Pt 2)

Associated symptoms Vertebrobasilar stroke: diplopia, dysarthria,

dysphagia, weakness, numbness Meniere’s disease: aural fullness, deafness,

tinnitus Psych/Panic attack: SOB, palpitations,

diaphoresis Multiple sclerosis: vertigo preceded by other

neurologic dysfunction

Establishing the cause of vertigo (Pt 3)

Prior risk factors migraine HTN, DM, smoking, PVD head injury psychiatric illness

Physical exam

Vestibular examNeurologic examSeverity of postural instabilityHearing tests

Peripheral vs Central Vertigo

Dix-Hallpike Maneuver

Peripheral vs Central Nystagmus

Further studies to evaluate vertigo

MRI/MRA -- distinguishing central causes

Audiometry -- distinguishing peripheral causes Brainstem evoked audiometry -- 90-95%

sens for detecting acoustic neuromas

Management of Vertigo

Treat the underlying disease migraine vertebrobasilar ischemia multiple sclerosis cerebellar tumors

Meniere’s disease: low salt diet, diureticsVestibular neuronitis (labyrinthitis):

antibiotics rarely needed BPPV: particle-repositioning maneuvers

Particle-repositioning maneuver

Management of Vertigo

Treat the underlying disease: migraine vertebrobasilar ischemia multiple sclerosis cerebellar tumors

Meniere’s disease: low salt diet, diureticsVestibular neuronitis (labyrinthitis):

antibiotics rarely needed BPPV: particle-repositioning maneuversDrug therapy, physical therapy

And the case starts over...

You quickly review the chart and see that the next pt is a 30 yo woman seen multiple times over the past years for LLQ pain, headache, allergies, and intermittent knee pain.

She states “I’ve been feeling dizzy.” It comes and goes, lasts up to 20 minutes, and gradually goes away.

Nonspecific dizziness

psychiatric disorders major depression 25% generalized anxiety or panic disorder 25% somatization disorder alcohol dependence personality disorder

hyperventilationoverlap with presyncope: CAD, CHF, PE,

dysrhythmias

And the case begins again...

You walk into the room of a 72 yo gentleman who tells you that he’s been feeling dizzy for the past few months. It happens throughout the day but is even worse when he has to get up to go to the bathroom in the middle of the night.

Disequilibrium

multisensory disorder due to any combination of: peripheral neuropathy visual impairment musculoskeletal disorder interfering

with gait vestibular disorder cervical spondylosis

Disequilibrium guidelines

inquire about neurologic and gait disorders

medications, especially antidepressants and anticholinergics

falling or dizziness while driving (needs intervention)

Presyncope

“nearly blacking out”, “nearly fainting”

lasts seconds to minutesorthostatic hypotensioncardiac arrhythmiasvasovagal attacks

Summary

Elucidate by history and confirm by physical

Majority of pts have vertigo, followed by nonspecific dizziness and disequilibrium

Most causes are benign and self-limitedSerious causes suspected by unilateral

hearing loss, abnormal neurological exam, or evidence of a central as opposed to peripheral cause of vertigo